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9-22-1999 A:00PM r�9t'I <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, <br /> Stockton, GA., 95202 <br /> 93450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ade in <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Aa a Health Division- <br /> San with <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standarrds of San Joaquin County Pu Services, EnvironmentalAS s 5-o-32 <br /> 1 1 Cross Street c Mc•n _City L <br /> WELL Location goo V c 4o ics✓%l a Zo STr Ohe 3II ell P1?Zo- -.fDO�phone# <br /> Address e!o r %` Gno- S+tee+ City Heys-ton Zip <br /> pROPERTY Owners '�on �iwt2 c L(,.L___ � r� � �� 1 �� 9y5$ Lic#yd / Phone>< 91 S•�!2-SBLY� <br /> a O k6 wa 4s_C'tYlJ->.c-u+o"ZIP_ . <br /> C•57 Contractor G � n� j-nQ Address _ _ PhonetF dna_935-9850 <br /> _ n I-` ,. ST City Se no inR—Lit# <br /> dtlress <br /> Consultant i Sup Contractor�.am 6f,o_ Range��Section <br /> G15 Cootd'mates:X�=Y�� <br /> Township <br /> WORK TO BE PERFORMED ; <br /> p DESTRUCTION(choose type pelow <br /> NEW WELL/BORING (CPT, GEOPROBE. p <br /> 1 HYDROPU2CH.iHAND-AUG/'.OTHER') OVER-BORE <br /> a PRESSURE GROUT <br /> "SOIL BORING yI Myy--p` - I <br /> WELL# "y- <br /> 'Other <br /> C—_%IMENTS: <br /> TYPE OF WELL CONSTRUE QE CONSTRUCTION SPEC�1F1CrATl MULTIPLE CASINGS"0 YES WNO WELL CASING DIA:* <br /> y+� <br /> MONITORING ('HOLLOW STEM DIA.OF BOREHOLE PVC Q OTHER: <br /> U EXTRACTION o AIR HAMMER/ORIVEN CASING THICKNESS '.ne TYPE TF CASING: E STEEL H AUGERS UHOSE <br /> DEPTH OF GROUT SEAL TREM(E TYPE TO BE UScO: (Y <br /> t)VAPOR MUD ROTARY y� 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUTS PUMPED: <br /> AIR SPARGE 0 PUSH POINT t�rta OLTEO TRAFFIC BOX or 0 STOVE PIPE <br /> I•SOIL BORING HAND AUGER APPROX. BORING OEPTH�.., — list specifications here):� <br /> CONDUCTOR CASING PROPOSED? <br /> OTHER: <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHIaIENT i tt-c1 11 111— ; I e Lows and Rulea <br /> ticanon and that the work will be done in accordance with San J ante of the work <br /> hereby certify that I have prepared[h�5 app tiront trot's hinng Or sup- <br /> for Regulations <br /> this of the is Joaquin <br /> shall not emploiry yvpersons ssubjectner of lice sed tonWORKMAN'S COMPENSATION •l � hat <br /> fo which <br /> g signature t is isss the,shalln of mpcertlfy that In the performance of the wok for which this permit is Issued. I shell employ persons subject to <br /> WORKMAN'S COMPENSATION Laws O/California.' <br /> n 7HE,APPLICANT MUST CALL 68 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> THE <br /> NSPECTION /�` <br /> Signed z <br /> Pla Title rcr�lii%l i /— X��ns rBate ��1 <br /> �Z �l �( /r'� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED o , <br /> �! EPARTMEN7 USE ONLY //f / /t-/L/ Area <br /> Date lssued�7(/L--:—J,_� <br /> Appliption Accepted By Date�� <br /> It t (� Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS f CONDITIONS: <br /> FAC: <br /> ACCOUNTING ONLY: AIO# <br /> H R'ECE�.V 0 / igA PERMITISERVICE REQUESTNUMBER INVOIC: <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKINJCAS <br /> Z <br />